Tinnitus

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Articles on Tinnitus in N Eng J Med, Lancet, BMJ

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Symptoms of Tinnitus

Causes & Risk Factors for Tinnitus

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2] Sabeeh Islam, MBBS[3]

Overview


Historical Perspective

  • In the early 19th century, Frenchman and Jean Marie Gaspard Itard introduced the concept of masking.  They were the first ones to differentiate between subjective and objective tinnitus.
  • Later in the 19th Century, with the introduction of germ theory and anesthesia, surgical therapy such as incudectomy was established.
  • Tinnitus is derived from the Latin word tinnire, meaning to ring.

Classification


Pathophysiology

Causes of subjective tinnitus

Common Causes

Sensorineural hearing loss:

  • Ototoxicity
  • Presbycusis
  • Noise induced hearing loss
  • Late onset congenital hearing loss
  • Idiopathic

Cochlear injury:

  • Ménière disease
  • Loop diuretics
  • Platinum based chemotherapy
  • Antibiotics
  • Salicylate
  • Trauma

Vascular causes:

  • Systemic hypertension
  • Sickle cell anemia
  • Small vessel disease
  • Hypercholesterolemia
  • Hypercoagulable state
  • Diabetic vasculopathy

CNS causes:

  • Pseudotumor cerebri
  • Stroke
  • Vascular malformations
  • Tumor
  • Sarcoid
  • Multiple sclerosis

Infections:

  • Rubella
  • Cytomegalovirus
  • Chronic otitis media
  • Neurosyphilis
  • Measles
  • Lyme disease
  • Meningitis

Bone disease:

  • Otosclerosis
  • Fibrous dysplasia
  • Osteogenesis imperfecta
  • Paget disease

Metabolic disorders:

  • Hyperparathyroidism
  • Chronic renal failure
  • Diabetes mellitus
  • Thyroid disease

Autoimmune diseases:

  • Autoimmune inner ear disease
  • SLE
  • Rheumatoid arthritis

Medications:

  • ACE inhibitors
  • Antimalarial medications
  • Aminoglycosides
  • Dapsone
  • Doxazosin
  • Calcium channel blockers
  • Benzodiazepines
  • Cisplatin
  • Clarithromycin
  • COX-2 inhibitors
  • Loop diuretics
  • Tricyclic antidepressant

Differential Diagnosis of Tinnitus


Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

  • Early clinical features include
  • If left untreated, patients may progress to
  • Common complications of

Diagnosis

History and Symptoms:

Physical Examination:

Laboratory Findings:

Imaging:

  • MRA and CTA are the gold standard diagnostic tests for arteriovenous fistula related tinnitus.
  • MRI with contrast is the initial preferred diagnostic test of choice for suspected vascular tinnitus.
  • MRI with contrast is followed by CT/CTA and ultimately interventional angiography, if needed.

Other Diagnostic Testing:

  • Initial audiometric tests are done to identify asymmetries between the ears and to locate the site of abnormality such as middle ear, cochlea, and brainstem.  These tests include:
    • Pure-tone audiogram
    • Tympanometry
    • Auditory reflex testing
    • Determination of speech discrimination abilities
    • Otoacoustic emissions testing
    • Auditory brainstem response testing (ABR)

Treatment

Tinnitus is a symptom and not a disease itself.  It is a chronic condition that can be managed by treating the underlying etiology.

Medical Therapy

Surgery

Prevention

References

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